Oncoplastic Breast Surgery

Laura DeYoung oncoplastic breast surgery patientKnowing Your Options

It had been two years since 67-year-old Laura DeYoung of Northbridge had gone for a mammogram. So alarm bells went off when her primary care physician Reynold Dahl, MD, felt a lump in her breast during a physical exam. She was immediately sent for a mammogram, an ultrasound, and then followed by a biopsy.

Once the results came in, Dr. Dahl asked her to visit his office where he delivered the news in person. “It hit me like a hammer,” she recalls. “That was the hardest part. Just to hear those words . . . breast cancer. I froze in the chair. You never think it’s going to happen to you, but boy, I got hit with it.”

Dr. Dahl referred Laura to Breast Surgeon Diana Caragacianu, MD, who is the medical director of The Breast Center at Milford Regional and Assistant Professor in the Department of Surgery at the University of Massachusetts Medical School.

Laura had mixed emotions following her diagnosis. She was still grieving the loss of her beloved husband after 42 years of marriage. Although she had an encouraging prognosis, Laura hated the idea of surgery disfiguring her breast and tainting the fond memories of her husband’s teasing compliments over the decades.

To her relief, Dr. Caragacianu gave her an option that many women don’t know about and that few hospitals offer—oncoplastic surgery, a procedure performed at the time of a lumpectomy to sculpt and restore the normal appearance of the treated breast. With oncoplasty, the focus is on conserving the breast in the setting of a larger tumor, allowing the complete removal of a tumor while minimizing and preventing disfiguring defects. This coordinated approach, which involves the breast surgeon and plastic surgeon, provides the benefit of everything being done in one surgery. Dr. Caragacianu brought her expertise with this procedure to Milford Regional a year ago after assuming the role as director of the Breast Center.

“I remove the breast tumor which creates a defect,” explains Dr. Caragacianu. “The plastic surgeon rearranges the remaining breast tissue to fill the defect, resulting in a normal appearing, lifted breast. We then do a reduction and lift on the other breast to achieve symmetry. It is distinctly helpful for patients with a big tumor. In the absence of practicing oncoplastic surgery and understanding which patients are candidates for this procedure, patients with a larger tumor may be given mastectomy as the only option or may be left with a very large unpleasant and cosmetically disfiguring defect in the breast. It allows more patients to choose breast conservation vs. mastectomy, prevents fluid accumulation, and results in a great cosmetic outcome.”

Laura underwent the oncoplastic procedure on Oct. 10 with Dr. Caragacianu performing the lumpectomy and sentinel node biopsy and Dr. Mustafa Akyurek, MD, PhD, of UMass Memorial Medical Group Cosmetic Surgery Center, doing the reconstruction. The two surgeons team up on all the oncoplastic procedures done at Milford Regional.

“Dr. Caragacianu explained my options right to the tee,” notes Laura. “It’s amazing how the surgery turned out. I am so glad I made the decision I did. I wanted my breasts to look perfect and they are! I really didn’t know if I could handle going back to do the reconstruction at another time.”

According to Dr. Caragacianu, Laura’s Stage 2 tumor was 2.4 centimeters and required removing about 8x5 centimeters of surrounding tissue, which would have resulted in a large hole without oncoplasty. “When we decide if a patient is a candidate for breast conservation, the size of the tumor relative to the size of the breast is very important” she explains. “Additionally, certain locations of the tumor results in worse defects than others, even in patients with small tumors. Therefore, location of the tumor is also a very important detail I consider when counseling the patient on the option for oncoplastic surgery. Laura would’ve had a very sucked-in defect close to the chest wall in the upper inner part of her breast, with no residual breast tissue in this location to mask the defect, while the remainder of her breast tissue was hanging in the lower part of her breast. The innovative approach of oncoplasty allows the breast surgeon to remove larger tumors with good margins, decreasing the risk of recurrence, and at the same time, work with exceptional plastic surgeons to not only normalize the breast back to its pre-surgery contour, but often times achieving an even better aesthetic cosmetic outcome. Psychologically, breast cancer patients tend to do better when their breasts are as close to normal as possible after surgery. Most patients are less bothered by a scar than by a hole in their breast. Also, when the patient is symmetric, the posture is better which helps in the recovery.”

Most women are familiar with a mastectomy and a standard lumpectomy, but oncoplasty is a less known option. Dr. Caragacianu explains that oncoplasty started in Europe in the 1990s and high volumes of these procedures have been performed there since then. It started gaining popularity in United States only over the last 10 years and many places across US are still slow to adopt these advances as options for patients. Dr. Caragacianu received training in oncoplastic surgery From Dr. Krishna Clough in Paris and Dr. Yves Jean Petit and the late Dr. Umberto Veronesi from the European Institute of Oncology in Milan.

“One reason for the slow adoption could be due to a breast surgeon’s lack of familiarity or comfort level with this procedure,” Dr. Caragacianu says. “Another reason is coordinating surgical time and care with the plastic surgeon. To offer oncoplasty, it is necessary to work in a multidisciplinary fashion with an excellent plastic surgery team, dedicated to reconstruction and easily available for cancer patients. We are very fortunate to have access to an amazing plastic surgery team led by Dr. Mustafa Akyurek, whose focus is excellent outcomes in reconstruction and aesthetics. Another aspect of oncoplasty is also patient education. Patients’ concerns surrounding reconstruction in general and oncoplasty in specific may be misperceptions about a longer recovery, and tumor recurrence or surveillance.”

One popular myth is that a cancer recurrence wouldn’t be as easily detected after reconstruction; however, Dr. Caragacianu stresses that reconstruction does not impact the chance of the tumor coming back or the ability to discover it. “It is all about how the physician educates the patient,” she explains. “Once you educate the patient that in most cases, oncoplastic reconstruction is safe, has no impact on the cancer recurrence or detection and that the recovery is quick, most patients who are oncoplasty candidates choose this option. The ideal candidates for oncoplasty are those patients whose tumor size and location would result in a large defect after breast conservation/lumpectomy procedure. In these patients, to avoid a mutilating large defect they are often counseled to undergo mastectomy. However, oncoplasty is an option that may save a patient from a mastectomy procedure if she desires breast conservation.”

Dr. Caragacianu continues, “Once I determine that the patient is a candidate for breast conservation and oncoplasty, taking into account tumor size, ration to breast size, location, planned radiation therapy, the patient’s case is presented at a Milford Regional and Dana-Farber/Brigham and Women’s multidisciplinary conference held at The Cancer Center on campus. The patient is then sent to see the plastic surgeon, Dr. Akyurek, before surgery is scheduled.”

Dr. Caragacianu notes that the best candidates have bigger and droopier breasts and a large tumor. Women with very small breasts aren’t great candidates for oncoplasty since they don’t have enough tissue to mobilize and rearrange to fill the defect,” she explains. “However, we do have other advances in autologous flaps allowing us to combine tissue rearrangement with a patient’s own tissue from other places on her body, or with liposuction and fat grafting.”

In some cases, Dr. Caragacianu points out that a woman will need a mastectomy— this includes patients whose tumors overtake the entire breast and have no option for or no significant response to systemic therapy; some patients with multiple tumors in the same breast (although there are now those who may be able to take advantage of breast conservation), and women with inflammatory breast cancer. She emphasizes that even mastectomy patients have reconstructive options. Sometimes reconstruction is done before radiation and sometimes afterwards, depending on the procedure and what’s recommended for that patient’s particular circumstances. “We offer nipple saving mastectomy, and reconstruction with implants or the patient’s own body tissue which is called flap reconstruction,” she notes. “We take into account what is the best operation for the cancer they have, the multimodal treatment they need, their overall health, and always give the patients choices. One of the most important aspects of our approach to optimize the patient’s treatment and surgical options is our management and decisions in a multidisplinary team involving the surgeon, medical oncologist, radiation oncologist and plastic surgeon. ”

Dr. Caragacianu explains that oncoplastic surgery takes about 2.5-to-3 hours and patients go home the same day. “We have many options that have great oncologic and cosmetic outcomes so that the patient doesn’t walk away having her cancer cured, but being disfigured,” she assures.

After her surgery, Laura was determined to attend her cousin’s wedding in Maine the following week. She traveled with family members and had “the time of her life”. She underwent radiation as the next part of her treatment plan, and now that the ordeal is behind her, enjoys the hours spent with her sons and grandchildren.

“I really am grateful that everything was done all in one shot and I didn’t have to go back for another surgery,” Laura says. “I have lots of nurses in my family, and they are so impressed with the outcome. If any woman had to go through this, I would recommend Dr. Caragacianu immediately, and I think it’s a good thing to have it done all at once. It’s what was best for me. I wanted to be put together the right way, and they did a wonderful job. I’m so fortunate. I love my surgeons and the reconstruction.”

Read more about The Breast Center, or to make an appointment with Diana Caragacianu, MD, call The Breast Center at 508-482-5439.

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